ABSTRACT
Herein, we present a case of emphysematous pyelonephritis with septic shock that was treated conservatively. A 44-year-old woman with diabetes mellitus presented to the emergency department with acute abdominal discomfort. Clinical examination revealed that the patient was conscious but vitally unstable. Therefore, the patient required inotropic support. A computed tomography scan revealed gas in the left kidney, suggestive of emphysematous pyelonephritis. Subsequently, the patient was treated conservatively and stabilized with broad-spectrum antibiotics, strict blood glucose management, and drainage.
ABSTRACT
People with diabetes mellitus have an increased risk of many common infections, such as urinary tract infections, lower respiratory tract infections and skin/soft tissue infections. This is caused by a combination of systemic and local host factors, and also specific organism characteristics. Individuals with diabetes mellitus also tend to acquire more complex infections, such as emphysematous cholecystitis and emphysematous pyelonephritis. Some conditions, such as malignant otitis externa and rhinocerebral mucormycosis, occur almost exclusively in people with diabetes. Despite greater susceptibility to infections and worse outcomes, there is little guidance regarding prevention and treatment measures for infections in those with diabetes. Comprehensive longitudinal studies are needed to further investigate the complex relationship between glycaemic control and infections. Copyright © 2022
ABSTRACT
Introduction: Emphysematous pyelonephritis (EPN) is a rare yet life threatening, necrotizing renal parenchymal infection with a mortality rate of 20-25%. With advent of CT, early goal directed therapy with antibiotics, aggressive treatment of sepsis and percutaneous drainage techniques, the mortality and morbidity rates are not as grim as earlier reports. Nephrectomy, treatment of the past has been replaced with nephron sparing surgery with better patient outcomes. A retrospective study was conducted at Government Kilpauk Medical College Hospital between January 2020 and April 2022. Diabetes, obstructive uropathy, structural abnormalities of the urinary tract and immunosuppression are well known risk factors for EPN. Malignancy and associated chemotherapy can make the vulnerable even more susceptible to EPN. The COVID19 pandemic, which was rampant for the past two years, with steroids being the cornerstone of management of COVID pneumonia also contributed to significant immunosuppression and poor glycemic control in many. This study wants to highlight along with traditional risk factors, the impact of COVID19 and Cancer on EPN. Methods: Demographic, clinical, radiological, and microbiological data of 33 patients were recorded. The data were analyzed to study risk factors, treatment modalities, need for hemodialysis, prognostic factors contributing to morbidity and mortality and patient outcome.The initial diagnosis of EPN at presentation was made by ultrasound evidence of gas in renal parenchyma, which was confirmed by CT imaging. Results: Out of a total 33 patients, 64% were females and the median age was 57.5 years. At presentation, common symptoms were abdominal pain (93%), renal angle tenderness (87%), fever (82%), vomiting (75%), dysuria (74%) and oliguria (65.9%). 81.8% (n=27) patients were diabetic. Urinary tract obstruction was present in 33.3% (n=11), Solid organ malignancy related EPN in 21.2% (n=7), with cancers involving kidney and urinary tract predominantly, concomitant COVID infection in 18.2% (n=6) patients, renal transplant EPN in 9% (n=3) of patients respectively. Most common organism was E.coli (60%) followed by Klebsiella spp.(10%), Pseudomonas (8%), Candida spp. (5.6%), Proteus mirabilis (1.4%) and culture negative EPN (15%). CT scoring was done by Huang and Tseng classification. Class I was documented in 28%, Class 2 in 58.8%, Class 3 in 11.8% and Class 4 in 2% of patients. DJ stenting was done in 55% of patients, percutaneous nephrostomy in 3% and the remaining patients improved with antibiotics alone. 35.7% (n=12) required dialysis,10.7% (n=4) were dialysis dependent at the end of three months with 9%(n=3) requiring dialysis indefinitely. Gender, glycemic status or uremic symptoms showed no statistical significance. Sepsis, shock, altered sensorium, higher serum creatinine and hemodialysis dependency had significant impact on patient's outcome. Conclusions: Early diagnosis and treatment with broad-spectrum antibiotics and properly timed interventions decreased mortality. Abdominal pain, renal angle tenderness and fever were the most common symptoms. E. coli was the commonest organism encountered. Solid organ malignancy contributed to a sizable portion of EPN in our study secondary to susceptibility to infections and obstruction. COVID19 infection is a risk factor for EPN due to worsening glycemic status and immunosuppression caused by steroid administration. No conflict of interest
ABSTRACT
CASE: A 78-year-old female with a history of recurrent nephrolithiasis and left ureteral reconstruction presented to our institution with hematuria, flank pain, anorexia and weight loss. 3-4 months prior, she had similar symptoms in her home country and was treated with multiple courses of antibiotics. She attempted to present to the US for evaluation earlier, but was unable to due to COVID. She first presented to a nearby US hospital and was diagnosed with an atrophic kidney with a superimposed infection based on imaging and labs. An EGD/ Colonoscopy done for her weight loss was unrevealing. She was discharged on antibiotics and told to follow up for possible nephrectomy. 1 days later, she presented to our institution with continued symptoms. Repeat CT was concerning for emphysematous pyelonephritis. Vital signs were unremarkable. Labs showed no leukocytosis, normal creatinine, hypercalcemia to 13.0 and urinalysis showed hematuria, pyuria and proteinuria. She was initially treated with IV antibiotics and a percutaneous nephrostomy for source control. To continue work up for her weight loss, a CT chest was done that showed multiple lung nodules and a re-review of the CT abdomen noted a T12 lytic lesion. 2 weeks into her admission, she had a left nephrectomy. Pathology revealed an invasive, grade 3, poorly differentiated squamous cell carcinoma arising from the renal pelvis, with lymphovascular invasion. A biopsy of the T12 lesion was consistent with metastasis. Due to her functional status and aggressive nature of her malignancy, palliative therapies were recommended. Patient's course was further complicated by ileus, massive aspiration and spinal cord compression from the T12 lesion. She passed away on hospital day 45. IMPACT/DISCUSSION: Squamous cell carcinoma of the renal pelvis is a rare malignancy. Most present at an advanced stage with a long history of nonspecific symptoms, such as hematuria and/or flank pain, which are typically attributed to recurrent nephrolithiasis;one of the most well-documented risk factors. Additionally, there are no characteristic findings on imaging, making radiological differentiation between renal SCC and other chronic infectious processes difficult. Often there is no suspicion for malignancy until the pathology results. For these reasons, renal SCC should be considered in patients who have underlying risk factors. One may also benefit from a renal biopsy, which can be done before a nephrectomy and has been shown to have a high degree of diagnostic accuracy. Adding to this diagnostic challenge, our patient's care was delayed due to COVID, demonstrating the importance of considering alternative diagnoses when patients have deferred presentations and fractured workups. CONCLUSION: Consider the diagnosis of renal SCC in patients with recurrent nephrolithiasis, UTIs, unexplained hematuria and/or flank pain and refer for a renal biopsy if appropriate. Be mindful of the impact of fragmented and delayed medical care on vulnerable patients.